CMS/EIP Fiscal Report Center: 52
Services beginning 07/01/2008 ending 09/30/2008 Date of Report:11/18/2008 Page: 1
Payclass Filters:OTHER
Eligibility Filter:Not Part C
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 1.00 48.50 48.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.50 97.00 38.80
Subtotal (Total Children Is Unduplicated) 3 3.50 145.50 41.57
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Total 3.50 145.50 41.57
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Number of Children (Unduplicated) With at Least One Service 3
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Center 52
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
3 3.50 145.50 0.00
Other 0 0.00 0.00 0.00
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Total 3 3.50 145.50 0.00